How Can I Avoid Humana Audits for Deceased Patients?
Humana has recently sent out audits to pharmacies with a subject line stating Review of claim(s) billed after member’s deceased date.
Entries by Jenevra Azzopardi, CPhT
Bill It Right – Diazepam Gel
Diazepam rectal gel continues to confuse prescribers and pharmacies alike when it comes to how a prescription is written and then ultimately filled and billed.
Prescription Quantity Changes Require Documentation
Anytime you dispense a quantity different from what was prescribed, you should note why.
Combivent® Respimat® Still Causing Confusion
The new inhaler was not an exact replacement of the old one. What happens if the plan will not allow a 20-day supply?
Be Audit Ready! Clinical Notes and Annotations: What Documentation is Essential for Audit?
Make sure you have good documentation of the conversation with the prescriber’s office to successfully pass an audit that may occur years later.
Prime Therapeutics and Express Scripts Partnership Muddies On-site Audits and Results
This partnership was designed to allow both companies to operate independently with ESI providing services to Prime, including performing some audits.
Small Differences Between Prescription Directions and Patient Label Can Lead to BIG Recoupments
PAAS National® recommends attention to detail when it comes to typing directions for patient labels.
Off-Label Use Not Covered Under Medicare Part D
PAAS National® has seen an increase in audit results from Elixir where the pharmacy was cited for “Claim not covered under Medicare Part D (NPD).”
Manipulating Quantity or Days’ Supply to Bypass Plan Limits Will Cost You
Plan limit rejections are intended to help control costs, provide clinical edits, and assist pharmacies in ensuring patient safety. When an initial claim adjudication is rejected for exceeding plan limits (e.g., Max Quantity Limit or Quantity vs Time Limit), pharmacies need to proceed with caution.
Centene® – Why Are They Leaving the PBM Game?
At the end of October 2021, Centene® executives said the company would be making a $30 billion request for proposals from outside contractors to take over the pharmacy benefit manager (PBM) side of their business. The request for proposal is expected to launch in 2022 and be awarded in 2023.
